Assistant Director, Claim Operations

Verda Healthcare; Huntington Beach (CA); Vor Ort; USD 95.000 - 120.000; Vollzeit

Benefits dieser Stelle

401(k)

Paid time off (vacation, holiday, sick

Health insurance

Dental insurance

Vision insurance

Life insurance

Zusammenfassung

Verda Healthcare, Inc. is seeking an Assistant Director, Claim Operations in Huntington Beach, CA to oversee daily claims processing and reconciliation, ensuring CMS and state compliance while supporting audits and operational excellence.

This leadership role partners with Claims Operations, Compliance, Finance, IT and delegated IPAs to optimize workflows, manage risk, and drive reporting and improvement initiatives.

Qualifikationen

• Bachelor’s degree or equivalent in related field preferred.
• Minimum 3+ years of experience in health plan, managed care, Medicare Advantage, IPA, TPA, or claims operations.
• Working knowledge of claims intake, adjudication, pricing, payment, reconciliation, denials, and provider disputes.
• Familiarity with CMS, state, health plan, and delegated entity requirements.
• Experience with claims systems and reporting tools; proficiency in Microsoft Office.
• Strong organizational, analytical, communication, and follow-up skills.

Aufgaben

• Support the Claims Director in monitoring daily claims operations, including intake, adjudication, payment, reconciliation, aging inventory, pending claims, and high-dollar claims.
• Track, document, and help resolve escalated claims issues involving providers, IPAs, internal departments, vendors, and delegated entities.
• Maintain claims dashboards, issue trackers, reconciliation reports, audit documentation, and operational reporting for leadership review.
• Ensure compliance with CMS, state, health plan, and internal requirements; keep processes and reports audit-ready.
• Assist with payment integrity reviews, including pricing validation, coding accuracy, and duplicate claim detection.
• Coordinate with stakeholders to support timely claim issue resolution and operational alignment.
• Prepare data, reports, and materials for internal reviews, audits, and leadership meetings.
• Support claim-related projects, system implementations, testing, and regulatory changes.
• Communicate effectively regarding claims escalations, provider inquiries, and project updates.
• Oversee daily claims routing and collaborate with IT, Delegation group, and Vendors.

Kenntnisse

Claims operations

Analytical thinking

Communication

Attention to detail

Project coordination

Ausbildung

Bachelor’s degree in business, healthcare administration, finance, public health, or a related field

Tools

Microsoft Excel

Jobbeschreibung

Verda Healthcare, Inc. is a Medicare Advantage Prescription Drug Plan (MAPD) organization committed to ensuring that underserved communities have access to health and wellness services.

Our mission is to ensure that underserved communities have access to health and wellness services and receive the support needed to live a healthy life that is free of worry and full of joy.

Position Overview

The Assistant Director, Claim Operations supports the Claims Director in the day-to-day oversight of claims operations for Verda Healthcare, Inc. This role helps ensure claims are processed accurately, timely, and in compliance with CMS, state, health plan, and internal requirements. The position provides operational, administrative, analytical, and project support across claims workflow monitoring, issue tracking, provider and IPA coordination, audit readiness, reporting, payment integrity, and process improvement initiatives.

This position reports to the Claims Director and works closely with Claims Operations, Provider Relations, Compliance, Finance, IT, delegated IPAs, vendors, and other internal stakeholders to support accurate claims administration, timely issue resolution, and continuous operational improvement.

Responsibilities

• Support the Claims Director in monitoring daily claims operations, including intake, adjudication, payment, reconciliation, aging inventory, pending claims, and high-dollar claims.
• Track, document, and help resolve escalated claims issues involving providers, IPAs, internal departments, vendors, and delegated entities.
• Maintain claims dashboards, issue trackers, reconciliation reports, audit documentation, and operational reporting for leadership review.
• Support compliance with CMS, state, health plan, and internal requirements by ensuring processes, documentation, and reports remain accurate and audit ready.
• Assist with payment integrity reviews, including pricing validation, coding accuracy, authorization linkage, duplicate claim identification, and overpayment or underpayment trend analysis.
• Coordinate with Provider Relations, Compliance, Finance, IT, delegated IPAs, and other stakeholders to support timely claims issue resolution and operational alignment.
• Prepare claims data, reports, status updates, and supporting materials for internal reviews, external audits, delegated oversight, and leadership meetings.
• Support claim‑related projects, system implementations, testing, process improvements, regulatory changes, and other departmental initiatives.
• Coordinate professional communications related to claims escalations, provider inquiries, project updates, and issue resolution.
• Oversee all the daily incoming, outgoing, and routing, work closely with the internal IT team, the Delegation group, and the Vendor.
• Perform other duties assigned in support of Claims Department goals.

Professional Competencies

• Demonstrates strong attention to detail, accuracy, and follow‑through in claims‑related work.
• Uses sound judgment, analytical thinking, and problem‑solving skills to support timely issue resolution.
• Communicates clearly and professionally with internal teams, providers, IPAs, vendors, and leadership.
• Maintains confidentiality, professionalism, and compliance awareness when handling claims, member, provider, and business information.
• Organizes work effectively, manages competing priorities, and meets deadlines in a fast‑paced environment.
• Collaborates across departments to support operational alignment, audit readiness, and continuous process improvement.
• Adapts to changing business needs, regulatory requirements, system updates, and departmental priorities.

Benefits

• 401(k)
• Paid time off (vacation, holiday, sick leave)
• Health insurance
• Dental insurance
• Vision insurance
• Life insurance

Schedule

• Full‑time onsite (100% in‑office)
• Hours of operation: 9am – 6pm
• Standard business hours Monday to Friday / weekends as needed
• Occasional travel may be required for meetings and training sessions.

Ability To Commute / Relocate

Reliably commute or plan to relocate before starting work (Required).

Physical Demands

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.

Requirements

Minimum Qualifications

• Bachelor’s degree in business, healthcare administration, finance, public health, or a related field preferred; equivalent claims operations experience may be considered.
• Minimum 3+ years of experience in health plan, managed care, Medicare Advantage, IPA, TPA, or claims operations environment.
• Working knowledge of claims intake, adjudication, pricing, payment, reconciliation, denials, pending, and provider dispute workflows.
• Familiarity with CMS, state, health plan, and delegated entity requirements related to claims administration is preferred.
• Experience using claims systems and reporting tools; proficiency with Microsoft Excel, Outlook, Word, and Teams required.
• Strong organizational, analytical, communication, and follow‑up skills with the ability to manage multiple priorities and confidential information.
• Demonstrated by overseeing all 837 files daily, incoming, outgoing, and routing, working closely with the internal IT team, Delegation group, and the Vendor.

Job Type: Full‑time employment
Location: Huntington Beach, CA
Compensation Range: $95K to $120K annually

Actual compensation offered will be determined based on experience, qualifications, skills, internal equity (if available), and geographic location. This position may also be eligible for performance‑based incentive compensation and benefits.